Provider Demographics
NPI:1194934208
Name:JEFFERSON PARK MEDICAL CENTER
Entity type:Organization
Organization Name:JEFFERSON PARK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATELAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-209-8405
Mailing Address - Street 1:4955 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2286
Mailing Address - Country:US
Mailing Address - Phone:630-209-8405
Mailing Address - Fax:773-736-1403
Practice Address - Street 1:4955 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2286
Practice Address - Country:US
Practice Address - Phone:630-209-8405
Practice Address - Fax:773-736-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046595Medicaid
IL036046595Medicaid